Infectious Disease Expert Discusses Delayed Treatment of Osteomyelitis

This case involves a teenage female patient who suffered a fracture of her left leg. She underwent a surgical procedure to stabilize the bone and was discharged. She returned to the hospital after experiencing increased pain. A wound culture was done at that time, and she was prescribed on antibiotics. The pharmacist noted she was allergic to this and the decision was made not to give the patient antibiotics due to her allergy. She was seen again in clinic and repeat cultures were done, which grew staph. However, no antibiotics were given. Her condition continued to worsen and she developed chronic osteomyelitis that progressed to septic shock.

Question(s) For Expert Witness

1. How often do you manage pediatric patients with osteomyelitis?

2. Briefly, what are the standard guidelines for treatment of osteomyelitis?

3. What are the complications of delay in treatment of osteomyelitis?

Expert Witness Response E-009690

I frequently practice both pediatric hospital medicine and pediatric infectious diseases. I care for patients with osteomyelitis on both of these clinical services. Our policy is that children with hematogenous osteomyelitis (i.e., osteomyelitis that occurs through bloodborne infection rather than following trauma or surgery) are admitted to the hospital medicine service and receive an automatic infectious diseases consult, so I see these patients in both my roles. In my infectious diseases role, I also care for patients with osteomyelitis following fractures or surgery.

For uncomplicated acute osteomyelitis, the usual treatment is the antibiotic cephalexin in most areas with clindamycin being first line in some areas with a high prevalence of methicillin-resistant S. aureus. Treatment is initially administered intravenously with a transition to oral antibiotics once there is improvement in clinical symptoms and inflammatory markers, such as the C-reactive protein. Certain cases merit bone biopsy to determine causative bacterium. I helped develop our local treatment guidelines and am a member of the national pediatric bone and joint guideline committee. However, based on the limited information provided, it is likely that the usual paradigm of osteomyelitis treatment does not necessarily apply in this case. Specific areas of consideration include initial treatment, determining mechanism of injury, how the wound culture was obtained, and timing of symptom-onset.

Delayed treatment initiation may lead to chronic bone infection, which can impair blood supply and lead to devitalized bone (i.e., bone death). In the short term, consequences of bone death may include requirement for multiple surgeries to remove dead bone. In the long term, bone death impairs normal bone growth, causing chronic disability (e.g., limp, chronic pain) or limb length discrepancy (if leg or arm bones are involved).